Mental health service delivery in South Africa from 2000 to 2010: One step forward, one step back

Inge Petersen, Crick Lund

Objectives. To identify progress and
challenges in mental healthcare in South Africa, as well as future
mental health services research priorities.

Method. A systematic review of mental
health services research. Literature searches were conducted in
Medline, PsychInfo and Sabinet databases from January 2000 to October
2010 using key phrases. Hand searches of key local journals were also
conducted. Of 215 articles retrieved, 92 were included. Data were
extracted onto a spreadsheet and analysed thematically.

Results. While progress in
epidemiological studies has been good, there is a paucity of
intervention and economic evaluation studies. The majority of studies
reviewed were on the status of mental healthcare services. They
indicate some progress in decentralised care for severe mental
disorders, but also insufficient resources to adequately support
community-based services, resulting in the classic revolving-door
phenomenon. Common mental disorders remain largely undetected and
untreated in primary healthcare. Cross-cutting issues included the need
for promoting culturally congruent services as well as mental health
literacy to assist in improving help-seeking behaviour, stigma
reduction, and reducing defaulting and human rights abuses.

Conclusion. While there has been some
progress in the decentralisation of mental health service provision,
substantial gaps in service delivery remain. Intervention research is
needed to provide evidence of the organisational and human resource mix
requirements, as well as cost-effectiveness of a culturally
appropriate, task shifting and stepped care approach for severe and
common mental disorders at primary healthcare level.

S Afr Med J 2011;101:751-757.

In 2000, Rita Thom published a
systematic review of mental health services research in southern
Africa, conducted from 1967 to 1999.1 The
review suggested a need to shift from centralised institutional care,
which characterised apartheid South Africa, towards decentralised,
integrated and community-based services provided within a human rights
framework. The use of trained non-specialists to provide mental
healthcare was also suggested as a strategy to increase access in the
context of a shortage of mental health specialists. Research gaps
identified included the need for accurate epidemiological studies;
intervention studies demonstrating the efficacy of sustainable models
of service delivery in line with policy imperatives for
deinstitutionalised and integrated primary mental healthcare; and
economic evaluation studies of service delivery models.2
The latter included cost-effectiveness, cost-benefit and cost-utility
analyses. Policies and legislation in post-apartheid South Africa have
been consistent with the suggestions emanating from this review in a
bid to increase access and quality of care within a human rights
framework.3,4 Emerging from the new Mental Health Care Act No. 17 of 20025
has been the introduction of a legislated 72-hour emergency referral
and observation period for mental healthcare users (MHCUs) in
designated regional and district general hospitals before onward
referral to tertiary hospitals. This innovation aimed to increase
availability and accessibility of mental health services locally in
less restrictive settings and reduce unnecessary referrals to
psychiatric hospitals.6
A further innovation included the introduction of Mental Health Review
Boards that have the explicit agenda of upholding the human and health
rights of people with mental disorders and intellectual disabilities.5

A recent review of decentralised community-oriented care in
Africa suggests, however, that many countries struggle to implement
policy imperatives for decentralised community-based care.7
In light of this, we set out to systematically review published
literature on mental health services research in South Africa from
January 2000 to October 2010, with the aim of assessing how South
Africa has fared in this regard over the past decade. Specifically, we
aimed to identify progress as well as remaining challenges in the quest
for improving access to high quality mental healthcare through
decentralised, integrated and community-oriented care, as well as
future mental health services research priorities.

MethodologySearch strategies

Literature searches were undertaken in the Medline, PsychInfo and
Sabinet databases from January 2000 to October 2010 using the key
phrases of ‘mental health services’, ‘mental health
systems’ and ‘South Africa’. Hand searches were also
conducted of the tables of contents of the following key local
journals: South African Medical Journal, African Journal of Psychiatry, South African Journal of Psychiatry and the South African Journal of Psychology. Inclusion criteria were that articles had to (i) report exclusively on a research study on South African mental health services; and (ii)
they had to provide information or recommendations about mental health
policy or treatment services in South Africa. Using these search
strategies, a total of 215 articles were retrieved. Of these 92 were
included on the basis of consensus reached on the above inclusion
criteria between the authors and a research assistant. We have
distinguished between studies and articles. Where articles report on
data sets from a single study, this has been mentioned.

Data extraction

Data were extracted onto a spreadsheet which included the following dimensions: (i) purpose/aim, (ii) design, (iii) sample/location, (iv) main findings and (v)
recommendations. The articles were then categorised according to:
epidemiological studies, status of mental health services, experiences
and perceptions of service users and carers, resource and costing
requirements, reviews, and intervention studies.

Data analysis

The findings and recommendations emanating from the articles were
synthesised according to the following main thematic areas covered by
the articles: tertiary in-patient care, decentralised psychiatric care
for severe mental disorders at primary healthcare (PHC) level,
decentralised care for common mental disorders (CMDs) such as anxiety,
depression and substance use disorders at PHC level, and cross-cutting
issues including HIV/AIDS and mental disorders, stigma and
discrimination, cultural congruence and resource requirements.

The majority of articles (45 (49%)) were concerned with providing
evidence of the status of mental healthcare services and experiences
and perceptions of service users. Five of these were published from
situation analyses data collected by the Mental Health and Poverty
Project, a multi-country study about mental health policy development
and implementation in 4 African countries.8
There were fewer epidemiological articles (37 (40%)), with 25 included
from the first nationally representative epidemiological study, i.e.
the South African Stress and Health (SASH) survey. There were 6 papers
published from 3 studies on resource requirements for mental
healthcare, 2 intervention study articles, and 3 review study articles.
The findings and recommendations have been synthesised according to the
main thematic areas outlined above, and are presented in Table I. The
review studies focused on specific issues of HIV threat and treatment
of persons with mental illness and substance use disorders;9 the interface between traditional healing practices and Western allopathic mental healthcare services;10 and service accessibility, utilisation and needs of Black South Africans with psychiatric disabilities.11

Tertiary inpatient care

The majority of articles included on tertiary inpatient care focused
on the problem of the revolving-door phenomenon that has accompanied
policy shifts towards de-institutionalised care. These articles suggest
that high rates of re-admission are mostly due to poor treatment
adherence and defaulting,12 substance abuse13,14,17,18 and early discharge owing to bed shortages.12,21 Concerning the latter, Lund et al. reported a 7.7% reduction in mental hospital bed numbers across all provinces in the 5 years ending in 2005.22
A recent study by Burns also showed that two-thirds of psychiatric
hospitals in KwaZulu-Natal surveyed over a 5-year period following
2002, experienced a drop in income at some point.23 Despite these reductions, community-based services remain under-resourced.22
No studies reported any increases in resource allocation for
community-based services during the review period. It is not surprising
that the main recommendations emanating from these articles relate to
the need for reductions in tertiary inpatient resources to be
accompanied by improved community-based rehabilitation and care
facilities.13,17,19,20,24

Other articles concerned the quality of inpatient care. Joska et al.,15
in a case study of a psychiatric hospital in the Western Cape, found
that the psychosocial needs of inpatients were not adequately met, with
the greatest need among the least educated. The need for improvements
in both inpatient and outpatient psychosocial rehabilitation programmes
was highlighted. Mayers et al.25 and Mkhize26
reported dehumanising experiences and human rights abuses in
psychiatric institutions and general hospitals. Both of these studies
were conducted after promulgation of the new Mental Health Care Act.5
They suggest lacunae in the implementation of the Act, which has the
explicit agenda of promoting care of MHCUs within a human rights
framework.

Decentralised community-based care

Observation and emergency care of MHCUs with severe and acute mental disorders at general hospitals
As mentioned in the introduction, the new Mental Health Care Act5 introduced
a 72-hour emergency management and observation period for MHCUs in
designated general hospitals across the country, as well as Review
Boards to protect the human rights of MHCUs. Studies conducted after
the promulgation of the Act suggest that implementation has not been
optimal. Although access to psychotropic medication is largely
available at inpatient and outpatient facilities,22 studies by Lund et al.22,27
found that infrastructure and specialist staff for the 72-hour
emergency management and observation service are mostly inadequate
across the country. A detailed study by Ramlall6 on
the implementation of the Act in KwaZulu-Natal over the 5 years ending
in 2010 found that 63.9% of designated general hospitals in the
province reported inadequate resources, including insufficient
designated beds, specialist staff and seclusion rooms to deal with the
demand and challenges of caring for disruptive patients – this
despite findings that 75.6% of admissions were involuntary or assisted,
indicating that the service caters mostly for MHCUs with severe mental
illness. Further, while Review Boards are meant to investigate human
rights abuses and neglect, the majority of hospital managers surveyed
in Ramlall’s study6
found the functioning of the Review Boards unsatisfactory in that they
were not able to address issues of inadequate infrastructure and
resources that contribute to human rights abuses and poor care.
Similarly, in the Western Cape, which has a concentration of tertiary
psychiatric hospitals, many MHCUs (22%) were found by Lund et al.22 to bypass the district hospital 72-hour observation period, being mostly admitted directly to tertiary institutions.

Concerning outpatient services, 3 articles report that PHC nurses
and doctors, who are often the first contact with the healthcare
system, reported insufficient training and support in emergency
management of MHCUs with severe and acute mental illness.20,28,29 Struwig30 also found that referrals to secondary level care had inadequate information.

Savings incurred as a result of budget cuts in tertiary psychiatric
care facilities have not been transferred to support community oriented
care.24,31
There is a shortfall in resources to adequately facilitate
de-institutionalisation policy imperatives, so leading to insufficient
dedicated beds in general hospitals, insufficient community-based
residential care, and poor information systems to monitor the
transitions to community-based care.27,34 In particular, there is a substantial shortfall in existing child and adolescent mental health services.35

It follows that recommendations for improving decentralised
emergency care and observation of MHCUs with severe and acute mental
disorders include: (i) demand for
additional resources at the district/regional hospital level,
particularly improved infrastructure and specialist staff; and (ii)
improved training and support of PHC doctors and nurses for management
and referral of cases as set out in the Mental Health Care Act.20,28,36 Mayers et al.25
also recommend training of MHCUs and service providers in users’
rights and the initiation of programmes to improve attitudes and
communication between MHCUs and service providers at general hospitals.
Given the role played by security personnel and the South African
Police Service (SAPS) in involuntary and assisted admissions,
strengthening of training of this sector in the Mental Health Care Act
was also recommended by 2 studies.17,25

Symptom management of severe mental disorders at PHC clinics

While 2 studies suggest that PHC clinic nurses are generally
comfortable with symptom management of chronic severe mental disorders
through the provision of maintenance medication,28,29 psychotropic medication is not universally available at PHC clinics across the country.22,37
This poses a threat to adequate treatment adherence and increases the
likelihood of defaulting, which was identified as contributing to the
revolving-door phenomenon.12,13,15,19,20 Two studies investigated MHCUs’ experiences of symptom management at PHC level;29,38
both revealed that MHCUs would prefer a dedicated psychiatric service
over an integrated service at PHC clinic level. In the main, this was
to obviate having to wait in long queues, which was reported in one
study to contribute to defaulting.38

Community-based psychosocial rehabilitation

A large number of articles (10) reveal gaps in community-based psychosocial rehabilitation programmes,15,17,22,29,39
particularly in rural areas. These articles corroborate those which
suggest that the revolving door phenomenon is partly due to inadequate
community-based care, including psychosocial rehabilitation. There has
been only one intervention study investigating the efficacy of a
modified assertive community-based treatment (ACT) approach that was
shown to have good outcomes for reducing the revolving-door phenomenon
and improving social and occupational functioning in high-frequency
users.44
ACT is individually based and fairly resource-intensive. It may
therefore not be appropriate for all service users in LMICs where
specialist resources are scarce, but may be cost-effective for
high-frequency users. Botha et al.44
suggest the need for a cost-benefit analysis of this approach for
high-frequency users who are likely to consume costly resources through
frequent admissions and use of police and prison services. An alternate
option for more low-frequency users is the adoption of a task shifting
approach to address community-based rehabilitation service gaps, which
was suggested by a number of studies in the review period.17,28,37 However, there are no intervention studies that provide evidence of the effectiveness of this approach in South Africa.

Identification and treatment of CMDs at PHC level
The SASH study revealed a 16.5% 12-month prevalence of CMDs45,46 and a lifetime prevalence of 30.3%.46,47
CMDs included anxiety, mood, impulse control and substance use
disorders. The SASH study found CMDs to be associated with chronic
physical illness, including hypertension,48 as well as being reported to be more disabling than physical disorders by respondents.49 However, a number of studies indicate irregular and inconsistent identification and treatment of CMDs at PHC level,22,28,42,50,51 corroborated by the SASH finding of a 75% treatment gap for CMDs nationally,52,53 with this gap being greater (>80%) when co-morbid with a personality disorder.54

Several factors have been identified as contributing to this gap,
including inadequate training of PHC personnel, limited time of PHC
personnel, and under-developed referral pathways.28,51,55
The need to address these issues through training and support of PHC
staff to close the treatment gap for CMDs in adults is underlined by
the SASH finding that the most common access to treatment is via
general practitioners.52

Integrated primary mental healthcare for CMDs needs to adopt a
stepped care approach which ensures identification and referral of CMDs
for either medical or psychological treatment as indicated. In addition
to mood and anxiety disorders, this approach needs to include substance
abuse as well as suicide risk. Substance abuse was identified by the
SASH study as being particularly problematic in men,56,57
while South Africans at higher risk of non-fatal suicide attempts were
found to be younger, female, less educated, from the Coloured ethnic
group, and have one or more DSM IV disorders.58,59

The need for referral pathways for trauma-related CMDs is
highlighted by the adverse impact of perceived racial and non-racial
discrimination on mental health,60,61 the psychological impact of HIV/AIDS bereavement,62,63
and findings from the SASH study that South Africans have experienced
and continue to experience a high number of traumatic events, including
politically motivated human rights violations committed under the
apartheid regime.64 Stressful life events, including traumatic events and relationship problems, were found to be predictive of CMDs.67,68

Psychological treatment can assist with many of these trauma-related
CMDs. While psychological services have been integrated into PHC to a
limited extent through the development of community psychology service
placements,69
the need for increased access to psychological treatment is given
impetus by several case studies that show that, where such services
have been provided, help-seeking for treatment of CMDs is evident.50,69
In the context of scarce psychological resources, two articles
recommend the adoption of a task-shifting approach for scaling up
psychological services whereby non-specialist workers provide
evidence-based psychological treatment packages, with support and
supervision from specialists.28,73

In addition to ensuring identification and treatment of CMDs in
general primary healthcare services for adults, the need for screening
and early intervention in children within both PHC settings and schools
is also highlighted by SASH findings that early-life mental disorders
have a negative effect on educational achievement and future
socio-economic prospects of individuals.74 The
high prevalence of CMDs in prenatal and postnatal women as well as
HIV/AIDS co-morbidity also suggests the need for mental healthcare for
CMDs to be integrated into vertical antenatal, postnatal and HIV/AIDS
clinic services. A study in 3 antenatal clinics in northern
KwaZulu-Natal revealed an extremely high prevalence of antenatal
depression (41%).75 Having an HIV-positive status has also been found to increase the risk of CMDs,76 as well as elevating the risk of suicide.77

Cross-cutting issuesModelling of resources required

Lund et al.27,31
have done extensive work in South Africa calculating the resources
required (beds, staff and facilities) to meet the service needs of
people with severe mental disorders; as well as the beds, staff,
facilities and budgets required to develop community-based mental
health services34 and to develop child and adolescent mental health services.35
These modelling studies take into consideration the need to balance
de-institutionalisation with the development of community mental health
services.

Cultural congruence

There have been several studies in the past decade that explored the
cultural congruence of mental health services in South Africa given the
diversity of cultures and languages.42,78
These studies indicated that a large proportion of the population hold
traditional explanatory models of illness; that MHCUs with severe
mental disorders often utilise both western public healthcare
facilities and traditional healing systems concurrently or
sequentially; that a minority of people with CMDs (about a fifth) seek
help from alternative healers including traditional healers and
spiritual advisors;83
and that there is little co-operation between the two systems of
healing. It is not surprising that recommendations emanating from these
studies and two other review studies10,11
include the need for greater co-operation between the two systems of
healing to promote cultural congruence, increased training of
traditional healers to promote mental health literacy, and research to
assess the efficacy of traditional treatments.81 In addition, Ruane84
identified language and class differences as barriers to accessing
psychological services in particular, with translation services not
being optimal or desirable, suggesting the need for more African
psychological service providers.85,86

Stigma and discrimination

Two studies suggested that some traditional explanatory beliefs promote stigma and discrimination.80,87 One of these found that being a beneficiary of a disability grant and having no employment can contribute to these problems.87 Stigma and discrimination can in turn contribute to defaulting82 and social isolation.42
Recommendations for reducing stigma and discrimination include
psychosocial rehabilitation and mental health literacy programmes for
service users, families and communities.80,87
A recent study suggests that while there are numerous anti-stigma
activities across the country, there is a need for more evaluation of
these activities and better understanding of what is effective.88

HIV/AIDS

As mentioned under the sub-heading of identification and treatment
of CMDs at PHC level, the need for HIV/AIDS treatment programmes to
include mental healthcare services is highlighted by a number of
studies reporting on the co-morbidity of HIV/AIDS and mental disorders.76,89,90 These studies reveal high levels of CMDs associated with HIV (47.3%),76 especially depression, HIV-related post-traumatic stress disorder (PTSD), alcohol abuse,76,89,90 and elevated suicide risk.77
Given the high rate of HIV in psychiatric patients, 2 studies also
indicated the need for mental health services to include HIV/AIDS
prevention interventions for MHSUs with severe mental disorders,
recommending staff training and institutional support to this end91,92 as well as the introduction of provider-initiated HIV testing for this population.93,94
One study indicates that individuals with anxiety or depressive
disorders are more likely to engage in inappropriate behaviour change
strategies95 and a further study demonstrated that men with CMDs may also be more prone to high risk sexual behaviour.96 These studies suggest the need for HIV risk reduction interventions with individuals with CMDs as well.

Concluding discussion

Building on research gaps identified in Thom’s review of
mental health services prior to 2000, this review indicates that there
has been significant progress with epidemiological studies, with the
SASH study providing the first nationally representative
epidemiological data base on CMDs. There has, however, been little
progress made with intervention and economic evaluation studies. These
remain research gaps, with close to 50% of the mental health services
articles reviewed reporting on descriptive studies of the status of
mental health services since 2000. A large number of these studies
focused on the effects of the new Mental Health Care Act.5
The need for this comprehensive systematic review of mental health
services research is highlighted by the finding that there had only
been 3 related review studies since 2000, all of which focused on
specific issues.

Collectively, studies on tertiary inpatient admissions and care,
symptom management at PHC level, and community-based psychosocial
rehabilitation provide corroborative evidence that there has been some
progress with decentralised care, but that a number of setbacks and
challenges remain. On the positive side, there is relatively wide
availability of psychotropic medication, and PHC clinic nurses are
generally comfortable with providing follow-up maintenance medication
for MHCUs with severe and chronic mental disorders. On the negative
side, while there has been a reduction in psychiatric hospital bed
numbers, there has not been sufficient investment in the development of
community-based psychosocial rehabilitative services to support
de-institutionalisation. The result has been
‘dehospitalisation’ and the development of the classic
revolving-door phenomenon. This has also been the case in other
countries where there were insufficient community-based rehabilitation
programmes to support de-institutionalisation.97
Further, a number of studies indicate that the introduction of the
72-hour emergency management and observation period in designated
regional and district hospitals in the absence of sufficient dedicated
infrastructure and specialist staff as well as inadequate training and
support of general staff, has negatively affected the quality of care
provided. The review suggests that, in the absence of dedicated
resources and adequate training and support of general staff, this
additional responsibility places further strain on an already
overburdened primary healthcare system, introducing the possibility of
human rights abuses that the MHC Act seeks to prevent.

De-institutionalised care is not a cheaper option, and Lund et al. have done extensive work on calculating the resources required for tertiary and community-based care.27,31 In keeping with international recommendations (e.g. by Thornicroft et al.),97
it is suggested that money saved from reduced spending on psychiatric
institutions be ring-fenced and decentralised, following MHCUs into
their community to ensure adequate community-based care. This would
provide the necessary finances for supporting the following key
recommendations to improve de-institutionalised care emanating from
this review: (i) The need for more
dedicated resources to support decentralised care within hospitals
designated to provide the 72-hour emergency management and observation
service, (ii) the development of
community-based psychosocial rehabilitation programmes harnessing task
shifting and self-help strategies that have been shown to have good
outcomes in other developing countries,98 (iii) public education to improve mental health literacy and access to care as well as reduce stigma and discrimination, and (iv)
the establishment of collaborative arrangements with traditional
healers to promote culturally congruent care, understood to involve
negotiation of care across language and cultural differences, including
specific organisational, system or service attributes that enable this.99

Regarding CMDs, descriptive service studies indicated poor
identification and treatment of these disorders at PHC level,
corroborated by epidemiological data from the SASH study that showed a
large treatment gap of 75% for CMDs.52
This treatment gap is a public health concern, given that CMDs have
frequent co-morbidity with cardiovascular disease, diabetes and poor
maternal and child health.100 They also increase risk for sexually transmitted disease,101 poor ARV treatment adherence,102 and accelerated disease course of AIDS.103,104

In the face of limited specialist resources, a recommendation for
closing the treatment gap for CMDs is the adoption of task shifting
within a stepped care approach. PHC staff servicing general as well as
vertical antenatal, postnatal and HIV/ARV clinics would need to be
trained and supported to identify CMDs, and manage and refer where
appropriate. Because PHC staff are overstretched, harnessing trained
community care workers to deliver manualised psychosocial interventions
for specific conditions, where appropriate, is suggested. There is
emerging international evidence of the effectiveness of such approaches
from other low- and middle-income countries.98,105,106
This approach also provides the potential for promoting culturally
congruent care by overcoming racial, class and language barriers that
act as impediments to help-seeking behaviour.

In line with the above service recommendations, future mental health
services research needs to focus on intervention and economic
evaluation studies of evidence-based culturally appropriate packages of
care using a task-shifting approach at the health facility and
community levels of care. These should include community-based
psychosocial rehabilitation and the identification and management of
severe and common mental disorders. Organisationally, intervention and
economic evaluation research is also needed to understand the human
resource mix and costing for the delivery of integrated packages of
care at district level, including training and supervisory needs,
organisational arrangements that promote cultural congruence, and
capacity development needs for staff, e.g. training and sensitisation
workshops and evidence-based programmes to improve communication and
attitudes of staff towards users with mental disorders.

Acknowledgement. We
thank Kim Baillie for the research assistance she provided on this
project, and for funding from the Mental Health and Poverty Research
Programme Consortium (RPC) funded by the United Kingdom (UK) Department
for International Development (DFID) (RPC HD6 2005-2010) for the
benefit of developing countries. The views expressed are not
necessarily those of the DFID.

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69. Pillay AL, Harvey BM. The experiences of the first
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70. Pillay AL, Kometsi MJ, Siyothula EB. A profile of patients
seen by fly-in clinical psychologists at a non-urban facility and
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70. Pillay AL, Kometsi MJ, Siyothula EB. A profile of patients
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71. Petersen I. Primary level psychological services in South
Africa: can a new psychological professional fill the gap? Health
Policy Plan 2004;19(1):33-40.

71. Petersen I. Primary level psychological services in South
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Identification and treatment of common mental disorders (CMDs) at PHC level

• Treatment gap of 75% for CMDs and general practitioner most common treatment source52

• Identification and treatment of CMDs at PHC level irregular and inconsistent22,28,42,50,51

• Reasons for lack of identification and management: inadequate training, insufficient time and paucity of referral pathways28,51,55

• Need for
referral pathways for trauma-related mental disorders highlighted by
the adverse impact of perceived racial and non-racial discrimination on
mental health,60,61 the psychological impact of HIV/AIDS bereavement,62,63 and high levels of traumatic events experienced by South Africans which are predictive of CMDs67,68

• Estimates of staffing, beds and facilities required for services for people with severe mental disorders;27 staffing, beds, facilities and budgets required for community-based mental healthcare for adults;34 and child and adolescent mental health services35

• Scale up
community-based care for adults and child and adolescent mental health
services, in line with the recommended service resources and budgets,
as per the national norms27,34,35

Cross-cutting issues – cultural congruence

• MHCUs with
severe mental disorders often use both western public healthcare
facilities and traditional healing systems of care concurrently or
sequentially, but there is little co-operation between the two systems
of healing42,78,107